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Blood Pressure Control – The Role of Single-pill Combination Therapies
persistent.
29
In a recent meta-analysis, non-compliance to the study single-pill combination therapies can help more patients reach
medication was reduced by around 25% in patients receiving a single- target BP, thereby reducing cardiovascular morbidity and mortality.
pill combination versus free drug combinations (see Figure 2).
30
In turn, this may translate into reduced numbers of physician visits
and hospital admissions, shortened hospital stays, reduced non-
Single-pill Combination and Tolerability Profile drug and overall healthcare expenditure and improved productivity.
Single-pill combinations are often advantageous over single agents in Thus, a wider use of single-pill combinations could potentially
terms of tolerability. Except for angiotensin II receptor blockers, the reduce the overall cost of treatments.
33
Whether this is indeed the
occurrence of adverse effects associated with antihypertensive drugs case has not definitively been proved. Today, there are large
increases with higher drug doses. Single-pill combinations usually variations among countries in the way single-pill combination
combine lower doses of the individual components and this translates therapies are paid for, and several financial barriers exist in some
into a reduced likelihood of adverse events. Again, there is a wealth of countries that limit wider use of these combinations.
data to support this statement. For example, hyperkalaemia is less
common with the combination of aldactone and hydrochlorothiazide Conclusions
(HCTZ) than with aldactone alone, and peripheral oedema is less Single-pill combinations have been shown to be valuable tools for
frequent when CCBs are associated with renin–angiotensin system the management of several medical conditions such as asthma,
blockers.
31
In one study,
32
elderly nursing home residents were diabetes and dyslipidaemia. They represent effective and
switched from a free combination of CCB and ACE therapies to a convenient alternatives to multidrug therapies with the individual
single-pill combination. After two months there were fewer reports of components. HTN represents another field where many single-pill
drug-related adverse events (75% less oedema) and significantly combinations are available with the potential to improve
lower per-patient costs. In a large meta-analysis of five different compliance and therefore outcomes. Considering the fact that a
categories of antihypertensive agent, the incidence of adverse effects substantial proportion of hypertensive patients are inadequately
with drug combinations was significantly less than additive, controlled despite the availability of effective antihypertensive
suggesting that antihypertensive agents given in fixed dose drugs because patients do not stay on therapy, wider use of single-
combinations do not potentiate the adverse effects of one another.
24
pill combinations should improve BP control by simplifying
treatment and reducing the pill burden. Today, most single-pill
One may also argue that the use of single-pill combinations is combinations involve dual therapies within one therapeutic area. In
associated with an increased risk of some side effects, for example the last few years, the first combination therapies across diseases
orthostatic hypotension and dizziness. In some elderly patients, (for example HTN and lipid disorders) have appeared on the market
the initial use of a single-pill combination may indeed be associated and could become increasingly popular.
34
In the near future, single-
with an excessive fall in BP, which would be deleterious if the patient pill combinations will probably include more than two components
suffered from a carotid artery stenosis or severe coronary heart in each pill; this could bring us to the expected polypill, which may
disease. This risk is higher when the first dose of the drug is taken. To further simplify the management of cardiovascular risk factors. ■
avoid this type of side effect, combinations should be available at
different doses. Alternatively, in such patients it may be wiser to start
Michel Burnier is a Professor of Medicine and Head of the Division of Nephrology and
with a monotherapy and use single-pill combinations as a second-line
Hypertension Consultation at the University Hospital of Lausanne in Switzerland. He is
therapy once the therapeutic situation has been stabilised. a member of several Swiss and international societies in the field of nephrology and
hypertension. He is a member of the Scientific Council of the European Society of
Single-pill Combination and Costs
Hypertension (ESH) and a committee member of the Swiss Society of Hypertension.
Professor Burnier is President Elect of the Swiss Society of Nephrology, President of
Uncontrolled HTN imposes a major health and financial burden on the ethical review board of the University of Lausanne and a Board Member of
society. Through a simplified therapeutic regimen, the use of single-
Swissmedic, the Swiss Agency for Therapeutic Products. He is on the Editorial Board of
several journals, including Hypertension and Blood Pressure. Professor Burnier trained in
pill combinations can increase compliance and persistence, thus
internal medicine and nephrology in Lausanne and at the University of Colorado
delivering enhanced effectiveness compared with their equivalent Health Science Centre.
monocomponents administered as separate pills. As a result,
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EUROPEAN CARDIOLOGY 55
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